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We all think about the environment when treating mental illness, but we regard it as secondary to helping symptoms and behaviour. Nidotherapy is the collaborative and systematic process of changing the physical, social and personal environment for people who have failed to respond fully to conventional treatments. It can be given by therapists unqualified in other specific treatment interventions and is highly cost effective, and so offers great advantages in health services constrained by cost pressures. This new edition has been fully revised, and includes new chapters on the principles of nidotherapy, the evidence for its effectiveness, its use in intellectual disability and those of limited mental capacity, the skills needed for nidotherapy, the economic benefits and common misconceptions. This comprehensive guide shows how nidotherapy can be used across the range of mental disorders and gives evidence for its value.

Health anxiety is an important new diagnosis that is increasing in frequency because of changing attitudes towards health, particularly excessive use of health information on the internet (cyberchondria). People with abnormal health anxiety become over-diligent monitors of their health, misinterpret most somatic sensations as evidence of disease, consult medical professionals unnecessarily and frequently, and are often over-investigated. Relatively few patients with health anxiety present to psychiatrists; most are seen in primary and secondary medical care. This paper reviews the diagnosis and presenting features of health anxiety, its identification in practice and its treatment. A range of simple psychological treatments have been shown to have long-lasting benefit for the disorder but are greatly under-used.

LEARNING OBJECTIVES

•To be able to identify abnormal health anxiety with the aid of probe questions

•To respond to people whom you have identified with excessive health anxiety in a way that facilitates its treatment

•To learn a few simple techniques derived from cognitive–behavioural therapy that can lead to long-term benefit

Most patients attending cardiology clinics will complain of, or experience, palpitations. This may be their sole presentation or coexist with other symptoms. Palpitations are the conscious awareness of the heart beating. They can vary in speed and rhythm, can be regular or irregular, and tend to be episodic.

Palpitations occur naturally on exercise and in situations that induce a high state of arousal, such as fear or excitement; they can also occur with a fever. Palpitations can also be associated with alcohol withdrawal or a consequence of taking large amounts of caffeine, classically in strong tea or coffee. In some individuals they can also give the sensation of an occasional missed heartbeat due to harmless, naturally occurring, benign extra beats (extrasystoles), where a delayed heart beat is compensated for by a stronger one following; these can also be accentuated by stimulants such as caffeine.

Palpitations can be natural, normal phenomena, but of course may also be present at times in people with confirmed heart disease; most clinically significant palpitations are associated with ischaemic heart disease, thyroid disease and valvular heart disease.

But, and this is a very big ‘but’, they are also very common in anxiety. Clinically significant causes of palpitations include:

• atrial fibrillation (very common, especially in the elderly, often in the presence of ischaemic heart disease; diagnosed by an electrocardiogram (ECG), but may be intermittent and so only detected on 24-hour recordings; patients may need anticoagulants to avoid strokes);

• Wolff–Parkinson–White syndrome (a form of rapid heart rate also diagnosed by ECG and usually harmless, although occasionally it is troublesome and may require surgical intervention);

• paroxysmal atrial tachycardia (can occur in all ages and is usually harmless; much more serious is ventricular tachycardia – it can require surgery and/or a pacemaker);

• ectopic beats (these are similar to benign extrasystoles, but here the underlying cause is ischaemic heart disease or thyrotoxicosis);

Goal-setting is an important way of marking progress for patients and instilling a sense of achievement. Goals elicit hope and when reached, demonstrate success.

Setting goals: short-term, medium-term, long-term

Goals can be short, medium and long term. They should be realistic, achievable and meaningful to the patient.

Short-term goals in the treatment of health anxiety can be related to the techniques used in therapy (e.g. being able to control excessive checking, or being able to resist looking up health issues on the internet; having successfully done the latter, a medium- or long-term goal could be using the internet again but being able to evaluate the information obtained in a non-threatening way).

Longer-term goals can be more difficult to set, as often patients with health anxiety cannot see a meaningful long-term future for themselves. They have just been preoccupied with illness or premature death. For this reason, it is important not to set these goals too early, that is to say, before the patient has started to make a cognitive shift. At the time the goals are made they should be seen as achievable, fitting in with the progress made in therapy.

Sometimes goals suggest themselves during therapy sessions. For example, the patient may say: ‘Because of all my problems we've not been able to have a holiday for years. I feel bad about this because I know my wife would like to get away, if only to visit the children’. This particular comment immediately suggests two potential goals, a medium-term one to visit the children (which would probably seem a relatively safe start), and the possibility of a proper holiday on their own in the longer term. For this example, it may be too early to mention this as a goal, but it could be suggested: ‘Has it been long since you visited? Would you like to be able to visit them again at some point?’. You could then note this down for bringing up at a later stage.

Some patients really struggle to come up with goals and often cannot produce one on the spot.

Patients frequently experience a period of relapse, even if it is only short. Discussion around this possibility is a crucial part of therapy. It should be done before therapy sessions are concluded, as the patient still needs to feel that they have some support. This may be triggered by a new health scare of some kind or some other external pressure, such as stress at work. It can be opportune if this occurs within the period of therapy so that further work can be undertaken to cope with potential problems in the future. Sometimes the last therapy session can be set at a more distant time in the future to allow for this.

Breaking down the problem into sets of potential triggers, followed by early warning signs of these, can help your patient to start to put in place the new skills that they have learnt in therapy straight away, and they can learn from the experience. It is also important for them to realise when and how they can ask for help. If the problem seems overpowering they need to be able to contact you, their therapist, or perhaps their GP, who should be aware of the problem early on. But they can also take the step of contacting you to explain they are having difficulties, outlining what they are doing to cope, so at least they know you are aware of the problem. Remember to recognise that they are trying to work through it on their own, and encourage them to contact you when they have got through it so you can congratulate them on how they have done. It is helpful to emphasise that a relapse is not going to be as bad, or last as long, as the initial illness and that they are in a better place now with new skills and beliefs.

Identifying potential triggers for relapse

Although the details of these are highly specific to your patient, there are some general pointers for all patients. Any major life event, such as a promotion at work, loss of a job, financial pressures, relationship difficulties, illness in family or friends, or the increased responsibility of having a child can trigger a relapse (see Case example 8.1).

Genitourinary medicine is as much about prevention of infection as it is about its detection and treatment. Patients who may have put themselves at risk of infection are encouraged to come forward for testing as many sexually transmitted infections, especially in the early stages, may be asymptomatic. Usually, there is a delay between contracting a sexually transmitted infection (STI) and the relevant test becoming positive. This can be as short as up to 2 weeks for gonorrhoea and chlamydia, and as long as 3 months for HIV and syphilis. So a patient attending for a check-up 3 weeks after an episode of unprotected sex, with negative screening, including that for HIV and syphilis, will have to re-attend 9 weeks later for the blood tests to be completed. This can be a very anxious time, particularly if they are in another relationship, as during this time they should practise safe sex or abstain.

There still remains a degree of stigma around sexual health and this can make it hard, if not impossible, for patients to talk about their worries with others, and very often this extends to health professionals too. In addition, unlike most other diseases that people fear, such as cancer, there is the issue of transmission and guilt is often a major issue that needs to be addressed in therapy. What is more, all this occurs within the context of intimate relationships, where trust can be seriously undermined and relationships potentially permanently damaged. Occasionally, test results can be equivocal and need repeating, and occasionally false–positive and false–negative results may be obtained. One person in a couple may test positive for an infection, but their partner may not, further adding to the confusion.

There is also the question of confidentiality and partner notification (contact tracing for the partners of infection). Patients are given clinic numbers and these, coupled with the patient's date of birth, are used to replace names on all biological specimens. You are not allowed to discuss any aspect of a patient's care with their partner unless they have given their express permission (ideally, clearly documented and signed). This can cause frustration for patients, even if you explain that it is official legislation and that you would be breaking the law, but there are ways of couching these issues in sensitive terms, so patients feel listened to and understood.

The essence of CBT is to encourage patients to identify their dysfunctional thoughts, beliefs and unhelpful behaviours, enable them to generate less threatening alternatives and then test them out. With health anxiety there is a tendency to overestimate the possibility of ill health, accompanied by the need to monitor health excessively in all the various forms that may take. The next sessions of treatment should include guidance on specific techniques to address these problems, particularly exploring how health anxiety is generated and fuelled, encouraging ways to achieve a more normal perspective on health and to put in place ways of maintaining this.

Techniques that help to alter distorted perceptions

Pie charts

The pie chart technique is helpful in two ways. First, it helps to generate non-serious, less threatening, alternative explanations for the patient's particular complaint, and it also helps put that complaint in perspective by working out the frequency of non-serious conditions.

The pie chart can be introduced by saying:

‘Let's make a pie chart of all possible causes of the particular symptom/ sensation that is troubling you.’

Thus, for example, if a patient's main cause for concern is an intermittent dry throat/cough, and they conclude that they have untreatable lung cancer, you jointly make a list of all the causes of a dry cough (remember, in this exercise we try to get the patient, not the therapist, to make most of the suggestions), which will of course include lung cancer, but should also include many less serious or non-serious causes; some basic medical knowledge can be helpful here. The severe, potentially life-threatening causes are best incorporated under one heading, avoiding the generation of a long list of severe illnesses. An example of such a list is given in Box 5.1. The idea is to generate so many innocuous causes in addition to the serious ones that it becomes apparent that the most serious outcome is the least likely.

I have written this book to help health professionals in their management of people who used to be diagnosed with hypochondria, but whom I think are better described as having health anxiety. I work mainly in general hospital settings and we now know that somewhere between 10 and 20% of all patients attending clinics in general hospitals have pathological health anxiety. It is pathological because it creates enormous suffering and disability and this often goes on for years in the absence of treatment. At present it is unfortunate that most of these people continue to attend clinics in search of a treatment not for their anxiety, but for the disease or diseases that they suspect they might have.

Although there are psychological services for people with health anxiety, only a small proportion of those with the condition are ever seen. This is partly because it is so common, partly because many people feel stigmatised by the suggestion that they might need psychological input for what they suspect is a physical condition, and partly because those who already have a physical disorder but also have abnormal health anxiety are not normally seen by the psychology services. I believe fervently that the best way of managing health anxiety successfully and economically is for front-line staff in medical services to both recognise and treat these patients in the clinics where they present repeatedly. They should be treated by staff who are part of the general services, not referred to a specialised clinic. So general and specialised nurses of all grades, occupational therapists, physiotherapists, dietitians, and support staff with relatively little in the way of formal qualifications, as well as psychologists, can all become competent in both identifying people with health anxiety and giving them advice and treatment. This is not a belief; it has recently been reinforced by evidence from a large randomised trial (Tyrer et al, 2013).

What I hope is that the necessary advice and treatment is given in this book. It is all based on my practice over the past 12 years and work in developing this treatment, and I am indebted to Professor Paul Salkovskis in first showing me the essentials of this important modification of cognitive–behavioural therapy (CBT) that lie at the heart of management.

Excessive, or abnormal, health anxiety is a form of anxiety focused on the belief of having, or fear of getting, a serious illness. The belief or fear is usually concerned with a medical illness and occurs without sufficient evidence of organic pathology to account for the symptoms, and despite medical reassurance. Both health anxiety and organic illness can coexist. For diagnostic purposes, health anxiety is normally not regarded as pathological until it has lasted for at least 6 months.

Worrying about health is a normal protective function. For example, in someone with a history of chest pain due to angina, the natural concern arising from more frequent attacks may prompt a medical consultation which could avert an impending myocardial infarction. Health anxiety becomes maladaptive when it is out of proportion to the medical risk. This could represent either a low level of anxiety when the risk is high, as, for example, indulging in frequent episodes of unprotected sex with many partners, with little or no consideration of the risk of acquiring a sexually transmitted infection, or experiencing excessive worry about a potential medical problem when in fact the risk of developing that condition is normal or very low.

Severity may range from mild concern to severe and constant preoccupation. The problem may also be transient; from time to time we all experience health anxiety which subsequently resolves, but for some it may become chronic and debilitating and cause severe suffering, which unfortunately in many cases becomes persistent.

The term ‘health anxiety’ is increasingly being used to describe patients with hypochondriasis. Its main advantage over hypochondriasis is that as well as being more accurate, it is less pejorative and therefore more acceptable to patients and makes it easier to broach the diagnosis. It is used throughout the text in this handbook, and is likely to become a formal diagnosis in the near future. In patients with this condition, preoccupation with health arising from cognitions based on the misinterpretations of bodily sensations and changes, generates a range of distressing emotions.

Breathlessness, or its medical term ‘dyspnoea’, is the prime complaint in respiratory medicine and a common complaint in cardiology. In this chapter we are considering primarily those patients who have been seen within respiratory medicine clinics, as those with breathlessness due to heart failure or coronary artery disease will tend to be seen in cardiology clinics, but obviously overlap between the specialties and conditions occurs.

Breathlessness is also a very common symptom of anxiety. It is a particularly frightening sensation, especially if patients feel that they are suffocating, and it is very easily misinterpreted as indicating underlying disease. Also, the anxiety generated by breathlessness occurring as a result of underlying respiratory or cardiac pathology can stimulate more fear, resulting in increased breathlessness due to superimposed hyperventilation.

One of the most common conditions encountered in out-patients is chronic bronchitis and its more severe consequences, chronic obstructive pulmonary disease (COPD) and emphysema, both of which are complicated by frequent superimposed chest infections. Asthma is also common, with wheezing as the predominant problem, but in some individuals attacks can be acute and very severe (there are occasional cases of sudden death in young people from asthma, and highly publicised cases such as these are often a major source of concern for the health anxious). Bronchiectasis is another chronic condition, where permanent lung damage is due to prior infection and it is characterised by the production of copious amounts of sputum; secondary infection is common here too. Cystic fibrosis is increasingly seen, as affected children now often survive into adulthood.

Other more acute conditions such as pneumonia and pulmonary embolus are often causes for concern as they are relatively common and well publicised. For example, advice is given repeatedly on how to prevent blood clots forming in the legs when flying to avoid a deep vein thrombosis and possible embolic complications. There are also repeated public health alarms about conditions such as bird flu and epidemics of diseases in different parts of the world that lead to special recommendations about travel.

I hope this section of the book, illustrating the practical application of the principles of cognitive–behavioural therapy in patients in different medical contexts, is helpful. I have focused on clinical conditions I have seen myself, but my belief is that all clinics in general hospitals will have people with abnormal health anxiety attending frequently, and the aim of these chapters is to show that the general approach I have described can be modified and used in all these situations. In each of them it is very helpful to have some knowledge of the pathology of each of the physical disorders commonly encountered in the clinics concerned. So nurses in dermatology clinics may frequently come across people with skin lesions, spots or blemishes that are clearly not serious, but it helps enormously to know which lesions do indicate a physical intervention. Similarly, in orthopaedic clinics people with joint and back problems may misinterpret symptoms when having physiotherapy and infer serious consequences that are part of health anxiety rather than progression of disease. It also helps greatly if the patient has confidence with the therapist's knowledge of physical illness, so that when they explore the psychological aspects, these only appear to be an extension of this knowledge rather than a ‘special mental health problem’. I have reminded people reading this book on many occassions in previous pages that worry over health is real and understandable, and when people engage in tackling the worry they are not having complex psychotherapy, they are just getting their symptoms back into proportion.

The recognition and simple interventions outlined can be applied by all health professionals – so please do not be inhibited and start helping people troubled by health anxiety now.

The diagnosis of health anxiety overlaps with other anxiety disorders such as generalised anxiety and panic; patients may also have depression. This associated pathology may also need to be addressed with a cognitive– behavioural approach. Comorbidity with confirmed organic pathology is also common and not a barrier to CBT; the major consequence of comorbidity is likely to be a modification in the form of behavioural experiments, and clarification with those directly responsible for the medical care of these patients is necessary in most cases. Other comorbidities such as psychosis, substance misuse or eating disorders may complicate therapy, necessitating referral for more specialist care.

There may also be issues surrounding bereavement or relationship difficulties that need to be addressed, and sometimes, particularly in individuals with comorbid organic pathology, fears regarding employment.

Excessive rumination

Some patients spend an enormous amount of time going over and over their worries in their minds. They find it hard to concentrate on anything else and can feel exhausted and depressed as a result. This can be a difficult symptom to control, but it can be helpful to ask the patient to consider thinking about the problem in the most worrying terms, telling you about it for 5 minutes. You ask them to rate their mood at the beginning and after the 5 minutes, when it will inevitably be lower, linking it to the cognitive theory of emotion (see Chapter 2, p. 8). You then ask them to consider a less threatening scenario, which you help them to construct. You can measure mood again after this, although initially it can be hard to find the scenario convincing. As homework they are asked to work on alternative scenarios, writing them down as fully as possible, then considering the relative merits of the two different interpretations.

Sometimes patients struggle to find an alternative, less threatening sequence of events, in which case special attention in therapy should be given to this in order to overcome rumination.

Health anxiety is especially common in neurology patients – one in four has the condition, a higher proportion than in other medical clinics (Tyrer et al, 2011a). Patients may just be offered a single appointment to exclude a more serious problem but they often have frequent investigations and when tests come back negative for underlying pathology, they tend not to be offered help for their anxiety.

Some of the most commonly feared conditions in health-anxious individuals are neurological illnesses such as brain tumours and multiple sclerosis (MS). Headaches are common in all people but frequently considered by the health-anxious patient to be evidence of a primary brain tumour or cerebral secondary deposits. Multiple sclerosis is often feared as it too is relatively common and the presenting symptoms are varied, tend to come and go (although not as frequently as health-anxious patients tend to believe) and accurate diagnosis is difficult. The symptoms of headache, perceived memory loss, clumsiness, twitching, involuntary movements, blurred vision, depersonalisation (the feeling of being unreal), dizziness and feeling faint, tingling in the extremities and trembling, are all common symptoms of anxiety but can also be part of neurological disease. They are frequently difficult to evaluate, and in many cases patients are overinvestigated for possible conditions such as Parkinson's disease.

Epilepsy is also a common condition and, as seizures can take many forms, sometimes this may be considered in anxious patients who experience depersonalisation – a distressing phenomenon where the patient feels as if they are detached from their surroundings, often accompanied by derealisation, the feeling that the surroundings too are strange. If this occurs frequently or is powerful enough, it may lead the clinician to suspect epilepsy.

Clarifying past medical communications

Multiple sclerosis is often considered as a differential diagnosis for non-specific neurological symptoms, and mentioning it in passing as a possible diagnosis can be extraordinarily worrying for patients, especially as in the early stages it can be difficult to confirm or refute. Patients worried by this can interpret every bodily sensation or change as evidence confirming the diagnosis. They frequently search on the internet for clues, and as the condition is so varied, they can easily find things to fit with their presumed pathology (Case example 14.1).